Worry and Generalized Anxiety Disorder: A Review and Theoretical Synthesis of Evidence on Nature, Etiology, Mechanisms, and Treatment

Worry and Generalized Anxiety Disorder: A Review and Theoretical Synthesis of Evidence on Nature, Etiology, Mechanisms, and Treatment
May 26, 2017 by
Worry and Generalized Anxiety Disorder: A Review and Theoretical Synthesis of Evidence on Nature, Etiology, Mechanisms, and Treatment

Generalised Anxiety Disorder is one of the most common and fundamental of all mental disorders, with symptoms and characteristics that reflect the core components of all other mood disorders. Despite being in some ways the “basic” disorder from which all other problems stem, GAD remains the least successfully treated. This review summarises current research into anxiety treatment.

Definitions and Clinical Features of GAD

Prevalence estimates for GAD range from 5% to 14% of the population, with women being slightly more likely to suffer from it than men.

GAD has high rates of comorbidity (being diagnosed at the same time as other disorders), especially with major depressive disorder. There is some debate as to whether GAD and MDD should be considered separate disorders, since they come from the same genetic root and are so often present together. However, research has shown that GAD does indeed feature different symptoms, risk factors and affects on cognitive functioning, suggesting that they are indeed separate disorders.

The mental strain caused by GAD is similar to that of MDD and greater than that of most alcohol and substance abuse disorders. GAD also poses serious risks to physical health, increasing the risk of death from all cardiovascular and heart related diseases. GAD is known to take a huge toll on society in terms of number of people requiring treatment and taking time off work.

GAD is often a chronic disorder that can last years. Even those who recover after successful anxiety treatment often still show some level of symptoms and rates of relapse are high. GAD also fluctuates on a day to day level and these changes can also slip over into the sleep cycle, negatively effecting a person’s ability to get a good night of rest.

Mechanisms in GAD


One of the central features of GAD is emotional hyperactivity, or greater shifts in emotion. For example, research shows patients with GAD were more reactive to negative events, show a greater intensity of negative emotions and feel less in control of their emotions. These tendencies are linked to the personality trait of neuroticism, which is to a large extent hereditary and explains how anxiety can be passed down in families. Part of this hyperactivity of emotions is caused by an increased sensitivity in the amygdala.


Those with GAD are thought to use worry as a coping mechanism, or as a way to master their chaotic emotions and feel more in control. Obsessively ruminating and worrying about things serves as an attempt to avoid high emotional extremes and reactions. However, evidence shows that using worry in this way often has the opposite effect- increasing and sustaining levels of negative emotion.

Another perspective on worry known as contrast avoidance states is that it is used to maintain a constant state of distress in order to “prepare” those with anxiety for an anticipated worst case scenario. Those with anxiety are highly sensitive to sharp shifts in emotions and so may prefer the sense of control and stable level of emotion that worry creates, even if it produces some level of distress. Better to be constantly worrying about something and be braced for it than experience a sudden and drastic change in emotion from not worrying about it. This causes people with GAD to constantly try to predict and expect negative outcomes and take a defensive stance to everything around them as their minds are constantly drawn to the worst case scenario.

Whatever the reason people end up worrying, it is often unhelpful. Worry increases negative feelings while failing to protect against future negativity, and also increases the duration of negative emotion and agitation. Despite this, people with anxiety often see worry as something useful that prevents worse feelings or outcomes from occurring.

GAD Risk Factors

Risk factors in environment and upbringing can all contribute to the development of GAD. These include traumatic life events, abuse and loss. Parenting is also thought to contribute to anxiety, particularly an infant’s relationship to their mother. An insecure attachment to the mother (or primary caregiver) characterised by being unsure if the caregiver is available or being rejected by her leads to avoiding relationships in the future for fear of further rejection.

Certain personality and temperament characteristics are also linked to a higher risk of anxiety, such as behavioural inhibition, which refers to a fear of new situations. Those with high levels of psychological arousal in response to new situations may show higher levels of contrast avoidance and be more likely to worry.

Interpersonal factors are also linked to GAD. Those with GAD are highly anxious to social threats and often perceive other people as threatening. They will therefore be hypervigilant for such threats- constantly on the lookout for sources of social distress- and this vigilance means they end up noticing more threats around them, and their anxiety levels continue to increase. High levels of anxiety also cause interpersonal problems, such as coming across as hostile or cold, and this leads to such people reporting fewer close friendships and being more likely to be divorced or separated. This lack of close relationships only serves to exacerbate their feelings of worry.

Treatment for Anxiety

Cognitive Behavioural Therapy (CBT) for anxiety is the most widely tested and supported anxiety treatment, with an abundance of research showing it can reduce anxiety symptoms and those of other comorbid disorders. Medication has also proved an effective means of reducing anxiety symptoms, although various drawbacks and side effects to medication have been reported.

Despite its success as an anxiety cure in many instances, CBT and therapy for anxiety and GAD still report lower success rates than for other anxiety disorders. Researchers have looked into different predictors of treatment success and identified the following factors which reduce the likelihood of treatment being successful:

  • Higher baseline levels of anxiety
  • Comorbidity with other disorders
  • Longer duration of illness
  • Marital tension and partner hostility
  • Tendency to interpret ambiguous information as threatening or negative
  • Interpersonal difficulties
  • Lower expectations from therapy and resistance to the therapist

Current research is aiming to examine whether different types of anxiety treatment will work better for people in different circumstances. For example psychodynamic therapy is shown to be more effective than CBT or medication in patients who also suffer from personality disorders, and long-term anxiety is more effectively treated by purely cognitive or behavioural therapy rather than mixed CBT. Treating the idea of contrast avoidance directly may be a new direction treatment could take by helping patients understand and confront their fears about sudden shifts in emotion in order to reduce the use of worry.


GAD is one of the most prevalent and lost-lasting anxiety disorders and treatments, while often effective, remain less successful than for other disorders. As researchers continue to further out understanding of the causes, symptoms and risk factors associated with GAD, new methods of treating anxiety will arise.

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Source :

Authors: Michelle G. Newman, Sandra J. Llera, Thane M. Erickson, Amy Przeworski and Louis G. Castonguay
Journal: Annual Review of Clinical Psychology
Source Title:Worry and Generalized Anxiety Disorder: A Review and Theoretical Synthesis of Evidence on Nature, Etiology, Mechanisms, and Treatment
Publish Date: Mar, 13